Improving Diabetes Prevention and Management

Grantee Name

Columbia University Mailman School of Public Health

Funding Area

Improving Diabetes Prevention and Management

Publication Date

May 2014

Grant Amount


Grant Date:

January 2012 – July 2012

The New York State Medicaid redesign effort has stimulated implementation of two new models of health care delivery: the patient-centered medical home (PCMH) and the Medicaid health home.

The health home in particular is designed to improve care and reduce costs for high-need Medicaid patients—those with multiple chronic conditions, such as diabetes and cardiovascular diseases. These new models of care require integrated and coordinated services across a continuum of medical, behavioral, and social services, as well as supportive community resources, such as housing. Community health workers (CHWs) can play a vital role in this care coordination and help to reduce health care costs and improve health outcomes for people with chronic diseases. However, providers have had little experience integrating CHWs into the PCMH or health home model. In 2012, NYHealth awarded Columbia University’s Mailman School of Public Health (Mailman) a grant to develop the New York business case for CHWs and guidelines for integrating CHW services into new models of health care delivery.

Outcomes and Lessons Learned

  • Integrated findings from a literature review, interviews of health home leaders, and the business case in a report, “Where is the Home in Health Home? Alternative Strategies for Community Health Workers to Enhance Effectiveness of the Health Home Team;”
  • Published conclusions from the case study of Bronx-Lebanon Hospital Center’s experience with creating a PCMH with CHWs in a report, “Pathways for Integrating CHWs into Patient-Centered Medical Homes: Lessons Learned from Bronx-Lebanon Hospital’s Department of Family Medicine ;” and
  • Contributed to a policy brief on integrating CHWs into health homes, “Making the Connection: The Role of Community Health Workers in Health Homes,” published by Health Management Associates.

Because implementation of Medicaid health homes was delayed, Mailman held discussions with two health homes, but did not provide technical assistance. In addition, a roundtable with health homes would have been premature, so this objective was replaced by a presentation of the grant findins at the American Public Health Association meeting in 2012.